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Biomechanical comparison of distal locking screws for distal tibia fracture intramedullary nailing  [PDF]
Brennen L. Lucas, Alexander C.M. Chong, Bruce R. Buhr, Teresa L. Jones, Paul H. Wooley
Journal of Biomedical Science and Engineering (JBiSE) , 2011, DOI: 10.4236/jbise.2011.44032
Abstract: Background: Newer generation intramedullary (IM) tibial nails provide several distal interlocking screw options. The objectives were to determine: 1) if the new oblique interlocking option provides superior stability, 2) which screw orientation/ configuration is the most biomechanically stable, and 3) if three distal interlocking screws provide better stability. Methods: A preliminary experiment was performed in torsion, compression, and bending tests with four different screw configurations: (I) one medial-to-lateral and one oblique, (II) two me-dial-to-lateral, (III) one medial-to-lateral and one anterior-to-posterior, and (IV) one medial-to-lateral, one anterior-to-posterior and one oblique in simu-lated distal metaphyseal fracture tibiae. Twenty- four Synthes EXPERT tibial IM nails were used for six specimens of each screw configuration. Parts I and II, tibial IM nails were locked with 5.0 mm in-terlocking screws into simulated distal tibiae (PVC and composite analogue tibia). Part III, the two most stable configurations were tested using five pairs of simulated cadaveric distal tibiae metaphy-seal fractures. Results: Significant differences were attributable to distal screw orientation for intrame- dullary nailing of distal tibia fractures. Configura-tions II and IV were found to be more stable than the other two configurations. No significant differ-ence was detected in construct stability in all modes of testing between Configurations II and IV. Dis-cussion: Configuration I did not provide superior stability for the distal tibia fracture fixation. Con-figurations II and IV provided equivalent stability. When choosing IM fixation for treatment of distal tibia metaphyseal fractures two medial-to-lateral screws provide the necessary stability for satisfac-tory fixation. Clinical Relevance: This study indi-cated an option for operative treatment of distal metaphyseal tibia fracture fixation where preserva-tion of soft tissue and rigid stabilization are needed.
Distal Tibial Metaphyseal Fractures: Does Blocking Screw Extend the Indication of Intramedullary Nailing?  [PDF]
Mugundhan Moongilpatti Sengodan,Singaravadivelu Vaidyanathan,Sankaralingam Karunanandaganapathy,Sukumaran Subbiah Subramanian,Samuel Gnanam Rajamani
ISRN Orthopedics , 2014, DOI: 10.1155/2014/542623
Abstract: Aim. To evaluate the clinical use of blocking screws as a supplement to stability in distal tibial metaphyseal fractures treated with statically locked intramedullary nail. Main Outcome Measurement. Alignment and reduction preoperatively, postoperatively, and at healing were the main outcome measured with an emphasis on maintenance of initial reduction on followup. Patients and Methods. This was a prospective study of 20 consecutive cases of distal tibial metaphyseal fractures treated with statically locked intramedullary nailing with supplementary blocking screw between August 2006 and September 2007 with a maximum followup of 3 years. Medullary canal diameter was measured at the levels of fracture and isthmus. Results. The mean diameter of tibia at the level of isthmus was 11.9?mm and at the fracture site was 22.9?mm. Mean length of distal fracture segment was 4.6?cm. Mean varus/valgus alignment was 10.3?degrees preoperatively and 1.7?degrees immediatly postoperatively and was maintained till union. Using Karlstrom-Olerud score the outcome was excellent to good in 90%. Conclusion. We conclude that the use of blocking screw as a supplement will aid in achieving and maintaining the reduction of distal tibial metaphyseal fractures when treated with intramedullary nailing thereby extending the indication of intramedullary nailing. 1. Introduction Treatment of metaphyseal fractures of tibia remains a challenge. The goals of surgical management include correction and maintenance of sagittal and coronal alignment, establishment of length and rotation, and early functional range of movements of knee and ankle. Interlocking nailing of tibial fractures is desirable because this technique allows some load sharing, spares extra osseous blood supply, avoids extensive soft tissue dissection, and is familiar to most surgeons. Nailing of metaphyseal fractures with short distal fragment is associated with an increase in malalignment particularly in coronal plane, nonunion, and need for secondary procedures to achieve union. The cause has been attributed both to displacing muscular forces and residual instability [1]. As there is a mismatch between the diameters of the nail and the medullary canal, with no nail-cortex contact, the nail may translate laterally along coronally placed locking screws and increased stress is placed on the locking holes to maintain fracture alignment after surgery [1]. Various techniques have been recommended to improve nailing the metaphyseal fractures including blocking screws (poller screw), temporary unicortical plating, percutaneous
A simple technique for on-table confirmation of locking screw Placement for cannulated intramedullary nails
BM Ndeleva, B Wanjira, CK Lakati, ML Lutomia
East African Orthopaedic Journal , 2012,
Abstract: Background: Locked intramedullary nailing is the standard of care for femoral and tibial shaft fractures. Correct placement of locking screws is often an ordeal followed at times by a tormenting wait for check radiographs to confirm whether or not the locking screws were correctly placed. Objective: We present a simple, inexpensive, fool-proof technique that confirms the correct placement of the locking screws on table thus allowing for revision at the time of surgery in case the locking screw missed the locking hole in the nail. Methods: The basis of this technique is that a screw or drill bit in the locking hole prevents advancement of a guide wire beyond the level of the screw or drill bit. The maximal length of wire that goes in is marked prior to locking. The most distal distal lock is placed first. If the lock is in place, then less of the guide wire will go in than what went in in the first instance. The length of wire that goes in up to the most distal lock is then marked and used to confirm the placement of the proximal distal lock. In the same manner, the distal proximal lock is placed followed by the most proximal lock in that order. Results: We have used this technique to confirm placement of locking screws in thirty nailing procedures and on all occasions, check radiographs confirmed that the locking screws were correctly placed as confirmed by this technique. Conclusion: This technique enables the surgeon to confirm correct placement of locking screws on table. It can be used with any cannulated nailing system. It is simple, in-expensive and foul-proof. As an adjunct during closed nailing under image intensification, the technique helps reduce operating time and exposure to radiation.
INTERLOCKED INTRAMEDULLARY NAILING OF LONG BONES
MANSOOR ILYAS
The Professional Medical Journal , 2008,
Abstract: Intramedullary interlocking nailing is the recommended procedure of fixation of long bones fracture. This type of fixation allowthe patient to walk independently in few days time, but unlikely there are only few centers in our country which are doing this practice. InMansoor Orthopedic Hospital and Sandeman Civil Hospital Quetta we started this type of fixation from November 2001 and we have done 15femoral (13 closed and 2 open GII) and 15 tibial (11 closed and 4 open GI & GII). Interlocking nails up till now. Our early results revealed 0%infection rate, breakage of nail in one case and bending of one distal locking screw. Inspite this in both cases fracture healed with out anysurgical intervention. Patient had nearly full range of movements of both knee & hip joint. We recommend close Intramedullary in interlockingnailing is an excellent technique to treat long bone fracture regarding good healing minimum complication shorter hospital stay and earlyfunctional rehabilitation.
Intramedullary Nailing of Femoral Shaft Fractures with Compressive Nailing Using Only Distal Dynamic Hole and Proximal Static Hole  [PDF]
Hakan Cift, Engin Eceviz, Cem Co?kun Avc?, Salih S?ylemez, Esat Uygur, Yal??n Turhan, Korhan Ozkan
Open Journal of Orthopedics (OJO) , 2014, DOI: 10.4236/ojo.2014.42005
Abstract:

Objectives: In this study we aimed to present our treatment results of intramedullary nailing of femoral shaft fractures with compressive nailing using proximal static hole and only distal dynamic hole with one screw. Methods: Forty-three patients who had a fracture of the femoral shaft were managed between 2005 and 2008 with intramedullary nailing and the use of only one screw for distal interlocking. Prospectively we evaluated the union time, possible reoperation, fixation and fracture alignment, range of knee motion and complications. Results: Union occurred within a mean duration of 18.7 weeks. No failures of the fixation and fracture alignment and no more than 1 cm shortness were detected. The knee range of motion was all more than 90 degree. Only one deep venous thrombosis was detected as complication. Conclusions: Compressive nailing using proximal hole and only distal dynamic hole with one screw is a convenient technique for femur fractures.

The Posteroanterior Locking for the Distal Humerus Nailing. Is It a Viable Option?  [PDF]
Yogesh Salphale, Jagannath Kaginalkar, Wasudeo Mahadeo Gadegone, Kiran Janwe
Surgical Science (SS) , 2017, DOI: 10.4236/ss.2017.811054
Abstract: The distal interlocking is regarded as an inherent part of the antegrade humeral nailing technique. Traditionally the distal locking of intramedullary humeral nails is achieved using a freehand technique. The humerus nailing locking options in the conventional nailing systems are placed in the anterior-posterior and lateral-medial directions. It exposes both the patient and surgeon to radiation, is time consuming, and has a potential risk of damaging neurovascular structures, especially the radial and lateral cutaneous nerve when the anterior-posterior and lateral-medial locking constructs are used. We aim to present a technical tip to ease the distal locking procedure and avoid the possible neurovascular complications with the existing nailing systems.
Screw Intramedullary Nailing for Fractures of the Humeral Shaft  [PDF]
Y. S. Salphale, W. M. Gadegone, R. M. Chandak, Jayeshkumar Dave
Surgical Science (SS) , 2015, DOI: 10.4236/ss.2015.68057
Abstract: The debate continues over the management of diaphyseal fractures of the humerus. There are a variety of extramedullary as well as intramedullary implants. We aim to propose a technique of passing the screw intramedullary nails and achieve union with least trauma to the shoulder and the rotator cuff. The multiple elastic screw nails achieve the inherent stability based on the principle of “three point fixation”. We aim to propose that the screw intramedullary nail is an effective implant to facilitate uneventful fracture union, with rapid recovery, low morbidity and low learning curve capable of being replicated in any smaller operative set up.
Locked intramedullary femoral nailing without fracture table or image intensifier
Rajesh Rohilla,Roop Singh,Seema Rohilla,Narender K. Magu,Ashish Devgan,Ramchander Siwach
Strategies in Trauma and Limb Reconstruction , 2011, DOI: 10.1007/s11751-011-0122-3
Abstract: The present retrospective study aims to evaluate the outcome in 41 patients of femoral shaft fractures, who had closed intramedullary nailing in lateral decubitus position without fracture table or image intensifier. Mean age was 33.2 (range, 18–70) years. The cannulated reamer in proximal fragment (as intramedullary joystick) and Schanz screw in the distal fragment (as percutaneous joystick) were simultaneously used to assist closed reduction of the fracture without the use of image intensifier. Closed reduction was successful in 38 patients. Open reduction was required in 3 patients. Schanz screw was used for closed reduction in 12 patients. Average number of intra-operative radiographic exposures was 4.4. Two patients had exchange nailing using large diameter nails. One patient had nonunion. Angular and rotatory malalignments were observed in seven patients. We are of the opinion that the present technique is a safe and reliable alternative to achieve closed locked intramedullary nailing and is best suited to stable, less comminuted (Winquist–Hansen types I and II) diaphyseal fractures of the femur.
Fatigue strength of common tibial intramedullary nail distal locking screws
Lanny V Griffin, Robert M Harris, Joseph J Zubak
Journal of Orthopaedic Surgery and Research , 2009, DOI: 10.1186/1749-799x-4-11
Abstract: Fatigue tests were conducted to simulate a comminuted fracture that was treated by IM nailing assuming that all load was carried by the screws. Each screw type was tested ten times in a single screw configuration. One screw type was tested an additional ten times in a two-screw parallel configuration. Fatigue tests were performed using a servohydraulic materials testing system and custom fixturing that simulated screws placed in the distal region of an appropriately sized tibial IM nail. Fatigue loads were estimated based on a seventy-five kilogram individual at full weight bearing. The test duration was one million cycles (roughly one year), or screw fracture, whichever occurred first. Failure analysis of a representative sample of titanium alloy and stainless steel screws included scanning electron microscopy (SEM) and quantitative metallography.The average fatigue life of a single screw with a diameter of 4.0 mm was 1200 cycles, which would correspond roughly to half a day of full weight bearing. Single screws with a diameter of 4.5 mm or larger have approximately a 50 percent probability of withstanding a week of weight bearing, whereas a single 5.0 mm diameter screw has greater than 90 percent probability of withstanding more than a week of weight bearing. If two small diameter screws are used, our tests showed that the probability of withstanding a week of weight bearing increases from zero to about 20 percent, which is similar to having a single 4.5 mm diameter screw providing fixation.Our results show that selecting the system that uses the largest distal locking screws would offer the best fatigue resistance for an unstable fracture pattern subjected to full weight bearing. Furthermore, using multiple screws will substantially reduce the risk of premature hardware failure.Tibial fractures are the most common long bone injury. Various methods of managing tibial fractures have been described in the literature over the years, ranging from plaster, functional b
Reamed interlocking intramedullary nailing for the treatment of tibial diaphyseal fractures and aseptic nonunions. Can we expect an optimum result?
Byron E. Chalidis,George E. Petsatodis,Nick C. Sachinis,Christos G. Dimitriou,Anastasios G. Christodoulou
Strategies in Trauma and Limb Reconstruction , 2009, DOI: 10.1007/s11751-009-0065-0
Abstract: The need for reaming and the number of locking screws to be used in intramedullary (IM) tibial nailing of acute fractures as well as routine bone grafting of tibial aseptic nonunions have not been clearly defined. We describe the results of reamed interlocked IM nails in 233 patients with 247 tibial fractures (190 closed, 27 open and 30 nonunions). Ninety-six percent of the fractures were united at review after an average of 4.9 years. No correlation was found between union and nail diameter (P = 0.501) or the number of locking screws used (P = 0.287). Nail dynamization was effective in 82% of fractures. Locking screw(s) breakage was associated with nonunion in 25% of cases. Bone grafting during IM nailing was found not to increase the healing rate in tibial nonunions (P = 0.623). None of the IM nails were removed or revised due to infection. A dropped hallux and postoperative compartment syndrome were found in 0.8 and 1.6% of cases, respectively. Anterior knee pain was reported in 42% of patients but nail removal did not alleviate the symptoms in almost half. This series confirms the place of reamed intramedullary nailing for the vast majority of tibial diaphyseal fractures. It provides an optimum outcome and minimizes the need for supplementary bone grafting in aseptic nonunions.
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